Repeat retroperitoneal lymph‐node dissection after chemotherapy for metastatic testicular germ cell tumour

Abstract

OBJECTIVES To examine the operative findings, histopathology and clinical outcome of patients undergoing repeat retroperitoneal lymph node dissection (RPLND) after initial chemotherapy and RPLND (PC‐RPLND) for metastatic testicular germ cell tumour (GCT), as a small proportion relapse or have residual disease after incomplete resection in the lung, retrocrural or pelvic nodes, and retroperitoneum. PATIENTS AND METHODS Between September 1992 and May 2006, 359 patients had PC‐RPLND under the care of one surgeon, 54 of which were repeat procedures. We compared the long‐term outcome between those having primary and those having repeat PC‐RPLND. RESULTS The median (range) time from original to repeat surgery was 2.4 (0.25–26.5) years, and the median follow‐up after the repeat procedure was 5.8 (0.08–12.9) years. There was no difference in survival between patients requiring only one PC‐RPLND and those having a repeat procedure (P = 0.592). The most frequent sites of recurrent disease were: behind the great vessels/para‐aortic areas (38, 46%), in the suprahilar region (18, 18%), in the retrocrural area (16, 19%), in the pelvic nodes (10, 12%) and in the lung (one, 1%). The most common pathological findings in the repeat PC‐RPLNDs were differentiated teratoma (19, 35%), malignant teratoma undifferentiated (nine, 17%), adenocarcinoma (eight, 15%) and necrotic tissue (five, 9.2%). CONCLUSION Although a small proportion of patients with metastatic GCT might require repeat PC‐RPLND, there is no difference in survival between this group and those having one PC‐RPLND. However, to avoid cancer recurrence and reoperation, it is crucial that the first PC‐RPLND is careful and complete, preferably done in a centre with expertise in this procedure.

Reoperative Retroperitoneal Surgery

“…Willis and colleagues, 41 from Charing Cross Hospital, reported on outcomes of 54 patients who underwent repeat RPLND following initial PC-RPLND. With a median follow-up time of 8.5 years, the investigators reported 5-and 10-year CSS of 94.2% and 91.3%, respectively.…”

“…Willis and colleagues 41 reported the Charing Cross Hospital experience of 54 patients who underwent reoperative retroperitoneal surgery following PC-RPLND. The overall reported perioperative complication rate was 9% (5 cases), including a deep venous thrombosis, chest infection, lymphocele, subphrenic collection, and right ureteric injury.…”

Redo Retroperitoneal Lymphadenectomy for Germ Cell Tumor of the Testis: Incan Experience (Instituto Nacional De Cancerologia, Mexico City) and Review of Literature

“…However the chemotherapy had limitations because relapses tend to be chemo resistant. 5 Results of published series demonstrate that insufficient initial surgery can not compensate by chemotherapy, 7,13,14 so it makes evident that repeat surgery is the last chance of cure for the patients. Completeness and adequacy of retroperitoneal resection is a independent predictor of clinical outcome.…”

The Evolution and Technique of Nerve-Sparing Retroperitoneal Lymphadenectomy

“…21 Similarly, a previous series reported retroaortic and/or retrocaval recurrence in approximately half of patients undergoing reoperative RPLND. 22 Although the optimal template that offers the greatest balance between oncologic control and minimization of morbidity in the setting of lowvolume nodal metastasis remains controversial, the importance of sparing postganglionic sympathetic nerves for preservation of ejaculatory function is not. Depending on the philosophy of the operating surgeon, reduction of the surgical template in early-stage disease allows for nerve sparing through the exclusion of dissection around the contralateral postganglionic nerve fibers in early-stage patients.…”